Robert W. Teasell

Social issues in the rehabilitation of younger stroke patients.

OBJECTIVES To study social factors and outcomes in stroke rehabilitation patients under the age of 50. STUDY DESIGN Retrospective chart review examining (1) martial status and employment status on admission and at 3 months post discharge, (2) discharge destination, (3) the presence of absence of children under the age of 16, and (4) psychosocial difficulties as recorded by staff during hospitalization. SUBJECTS AND SETTING Eighty-three consecutive stroke patients under the age of 50 admitted to a Canadian tertiary-care hospital rehabilitation unit. MAIN OUTCOME MEASURES Discharge destination and primary caregiver at discharge, and return to work and marital separation 3 months after rehabilitation discharge. RESULTS Of the 55 patients with spouses, 8 (14.5%) separated within 3 months of hospital discharge. Fifteen of the 83 patients (18.1%) were not able to return to their premorbid place of residence; 4 (4.8%) required institutionalization. Of the 64 patients employed outside the home or studying at the time of their stroke, only 13 (20.3%) were able to return to work within 3 months of their discharge to home. Only 9.4% of those working full-time were able to return to full-time employment. CONCLUSIONS Rehabilitation of young stroke patients is associated with a variety of social problems, including marital breakup, child care responsibilities, and return to employment, which are uniquely important in this age group.

Employment-related factors in chronic pain and chronic pain Disability

Background: Disability is a multifactorial phenomenon. Social scientists suggest that nonclinical factors, including age, education, and job status, correlate with disability. Objective: Do employment-related factors predict chronic pain and/or chronic pain disability? Methodology: The literature search identified 15 observational studies to provide the evidence about this question. Results: Review topics included job satisfaction, type of work, modified work and work autonomy, other employment-related factors, and socioeconomic status. Most subjects in the studies had low back pain. The studies used return to work as an outcome predicting chronic pain disability. Conclusions: Lack of modified work and lack of work autonomy predicted chronic pain disability (level 2). There was limited evidence (level 3) that lack of job satisfaction, perception of difficult job conditions and demands, heavy physical demands of the job, private rather than public employment, and lower socioeconomic group predict chronic pain disability. The number of years employed varied as a predictor in different studies (level 4b).

The Incidence, Management, and Complications of Dysphagia in Patients with Medullary Strokes Admitted to a Rehabilitation Unit

The objective of this study was to examine the frequency of dysphagia symptoms and related consequences in medullary stroke patients admitted to a stroke rehabilitation unit. A chart review of a cohort of 563 stroke patients admitted to a rehabilitation unit was used to identify patients with evidence of predominantly medullary lesions. The results of both initial and followup videofluoroscopic modified barium swallowing (VMBS) studies were also reviewed for evidence of aspiration and residuum in patients with dysphagia. Twenty of the 563 patients (3.6%) were diagnosed with a medullary stroke. Eleven of the 20 (55%) patients were identified clinically with dysphagia and nine had at least one (VMBS) study. All dysphagic patients demonstrated some degree of either aspiration or residuum on both initial and final swallowing studies and received some form of dietary modification. Comparisons between patients with and without dysphagia demonstrated significant differences with regard to length of hospital stay and the development of pneumonia (p <0.05). More than half of the patients with medullary strokes presented with clinical indications of dysphagia, were more likely to develop aspiration pneumonia, and experienced longer hospital stays. Aspiration pneumonia appeared to be an early complication of stroke and dietary modifications did not prevent its development.

Compensation and chronic pain.

Background: The literature contains many different viewpoints on the impact of compensation on recovery from chronic pain. Objective: What is the role of compensation in chronic pain and/or chronic pain disability? Methodology: The literature search identified 11 observational studies to provide evidence about this question. Results: There is a paucity of high-quality data on the subject of the impact of compensation on chronic pain. This subject was reviewed under the headings of (1) injury claim rate and duration; (2) recovery; and (3) rehabilitation treatment programs. The studies were of subjects with musculoskeletal pain, mainly low back pain. Conclusions: Filing a compensation claim for costs, retaining a lawyer, or higher pain intensities were limited predictors of longer claims (level 3). As the ratio of compensation to preinjury wage increases, there is moderate evidence (level 2) that the duration of the claim increases and that disability is more likely. Compensation status, particularly combined with higher pain intensities, is associated with poorer prognosis after rehabilitation treatment programs (level 3).

Misdiagnosis of conversion disorders

Teasell RW, Shapiro AP: Misdiagnosis of conversion disorders. Am J Phys Med Rehabil 2002;81:236–240.Five cases are presented describing the clinical features for which they were referred and admitted to a rehabilitation unit and later identified as having been misdiagnosed as having a conversion disorder. The diagnoses were sarcoma-induced osteomalacia, cerebellar medulloblastoma, Huntington’s chorea, transverse myelitis, and lower extremity dystonia. A perceived history of psychological difficulties, an unusual neurologic presentation, and normal initial diagnostic testing in a female patient were associated with a misdiagnosis of conversion disorders; unfortunately, these factors also characterize actual conversion disorders.

Poststroke seizures in stroke rehabilitation patients

The incidence, seizure type, location and type of stroke, and anticonvulsant medications, including adverse effects, were studied in a stroke rehabilitation population. Of 563 consecutive stroke patients admitted to the rehabilitation unit, 14 had a history of a seizure and were excluded from the primary study group. Of the remaining 549 stroke rehabilitation patients, 43 (7.8%) suffered a poststroke seizure (PSS). When only hemispheric patients were studied, the incidence of poststroke seizures rose to 43 of 460 (9.3%) as no brainstem stroke patients suffered seizures. The average age of the PSS patients was 55.4 years. The incidence of PSS in all stroke infarction patients was significantly smaller (22 of 450, 4.9%) when compared with hemorrhagic strokes (21 of 99, 21.2%) (P<.001). The incidence of PSS among hemispheric infarcts was 22 of 379 (5.8%) versus 21 of 81 (25.9%) of hemispheric hemorrhagic strokes (P<.001). Twenty-six PSS patients had primarily cortical involvement, 13 had both cortical and subcortical involvement, and only 4 had primarily subcortical involvement. Seizures occurred within the first 24 hours in 23.8% of stroke patients, 52.4% within the first week, in 66.7% within the first month, in 83.3% within the first 6 months, and in 88.1% within the first year. In the 43 patients with PSS, 19 (44.2%) were reportedly focal in nature, 12 (27.2%) were generalized, and 6 (14.0%) were focal with secondary generalization. Three (7.0%) were complex-partial seizures and 3(7.0%) were of an undetermined type. Of the 14 stroke rehabilitation patients excluded from the study group because of a prestroke seizure, 6 (42.9%) suffered a PSS in contrast to the 43 of 549 (7.8%) with no premorbid history of a seizure (P<.001).

Management of Aspiration and Pneumonia Following Stroke

Aspiration has been associated with pneumonia following stroke and its detection and prevention are considered important in the management of stroke patients. Initially, a bedside assessment is conducted, especially in high-risk patients. However, clinical assessment may miss a substantial number of “silent” aspirators and therefore the videofluoroscopic modified barium swallow (VMBS) study is considered the “gold standard” for confirming the presence and extent of aspiration. Clinical indications for use of VMBS studies remain empirical and have never been scientifically validated. Treatment of known aspiration involves specialized diets and in more severe cases, nonoral feedings. Only a little quality scientific research demonstrates whether such treatments are effective or ineffective in preventing aspiration. An obvious need exists for further research into this area.